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Men’s health 2018: BPH, prostate cancer, erectile dysfunction, supplements

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Release date: November 1, 2018
Expiration date: October 31, 2019
Estimated time of completion: 1 hour

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ABSTRACT

This review describes the latest research and guidelines for 4 topics in men’s health commonly addressed by primary care physicians: the diagnosis and treatment of benign prostatic hyperplasia (BPH), prostate cancer, and erectile dysfunction and the evidence concerning the use of dietary supplements in men.

KEY POINTS

  • The combination of an alpha-blocker and a 5-alpha reductase inhibitor is an effective regimen for BPH. Withdrawing the alpha-blocker from the combination can be considered if symptoms have been well controlled after 1 year of combination therapy.
  • A new look at 2 large trials of prostate-specific antigen screening strengthened evidence that testing in the right patient population can reduce deaths from prostate cancer, but a third recently published trial found no benefit to 1-time screening.
  • Magnetic resonance imaging offers a better method than ultrasonography-guided biopsy to triage patients thought to be at high risk of prostate cancer and tends to limit costly overtreatment of disease that likely would not cause death.
  • Erectile dysfunction is often associated with chronic disease and may suggest the need to screen for cardiovascular disease.


 

References

Primary care physicians are tasked with a wide variety of issues affecting men. This article reviews the latest research in 4 areas of men’s health commonly addressed in primary care:

  • Medical management of benign prostatic hyperplasia (BPH)
  • Prostate cancer screening and treatment
  • Medical management of erectile dysfunction
  • Use of supplements.

See related commentary

MEDICAL MANAGEMENT OF BPH

An 84-year-old man with a history of hypertension, type 2 diabetes, hyperlipidemia, BPH, mild cognitive impairment, and osteoarthritis presents for a 6-month follow-up, accompanied by his son.

Two years ago he was started on a 5-alpha reductase inhibitor and an alpha-blocker for worsening BPH symptoms. His BPH symptoms are currently under control, with an American Urological Association (AUA) symptom index score of 7 of a possible 35 (higher scores being worse).

However, both the patient and son are concerned about the number of medications he is on and wonder if some could be eliminated.

Assessment tools

BPH is a common cause of lower urinary tract symptoms in older men. Evidence-based tools to help the clinician and patient decide on when to consider treatment for symptoms are:

  • The AUA symptom index1
  • The International Prostate Symptom Score (IPSS).2

An AUA symptom index score or IPSS score of 8 through 19 of a possible 35 is consistent with moderate symptoms, while a score of 20 or higher indicates severe symptoms.

Combination therapy or monotherapy?

Monotherapy with an alpha-blocker or a 5-alpha reductase inhibitor is often the first-line treatment for BPH-related lower urinary tract symptoms.3 However, combination therapy with both an alpha-blocker and a 5-alpha reductase inhibitor is another evidence-based option.

The Medical Therapy of Prostatic Symptoms study,4 a randomized controlled trial, reported that long-term combination therapy reduced the risk of BPH clinical progression better than monotherapy. The same trial also found that either combination therapy or finasteride alone (a 5-alpha reductase inhibitor) reduced the risk of acute urinary retention and the future need for invasive therapy.

Monotherapy after a period of combination therapy?

There is also evidence to support switching from combination to monotherapy after an initial treatment period.

Matsukawa et al5 examined the effects of withdrawing the alpha-blocker from BPH combination therapy in a study in 140 patients. For 12 months, all patients received the alpha-blocker silodosin and the 5-alpha reductase inhibitor dutasteride. At 12 months, the remaining 132 patients (8 patients had been lost to follow-up) were randomized to continue combination therapy or to take dutasteride alone for another 12 months. They were evaluated at 0, 12, and 24 months by questionnaires (the IPSS and Overactive Bladder Symptom Score) and urodynamic testing (uroflowmetry, cystometrography, and pressure-flow studies).

There were no significant differen­ces in subjective symptoms and bladder outlet obstruction between patients who continued combination therapy and those who switched to dutasteride monotherapy. In the monotherapy group, those whose symptoms worsened weighed more (68.8 kg vs 62.6 kg, P =.002) and had a higher body mass index (BMI) (26.2 kg/m2 vs 22.8 kg/m2, P < .001) than those whose symptoms stayed the same or got better.

These findings of successful alpha-blocker withdrawal were consistent with those of other studies.

The Symptom Management After Reducing Therapy study6 showed that 80% of men with an IPSS score less than 20 who changed to dutasteride monotherapy did not have a noticeable worsening of their symptoms.

Baldwin et al7 noted similar success after withdrawing the alpha-blocker doxazosin in patients on finasteride.

Review all medications

The National Health and Nutrition Examination Survey noted that the estimated prevalence of polypharmacy increased from 8% in 1999 to 15% in 2011.8 Many commonly used medications, such as decongestants, antihistamines, and anticholinergic agents, can worsen BPH symptoms,9 so it is reasonable to consistently review the patient’s medications to weigh the risks and benefits and determine which ones align with the patient’s personal care goals.

BPH: Take-home points

  • Combination therapy with an alpha-blocker and a 5-alpha reductase inhibitor is an effective regimen for BPH.
  • Polypharmacy is a significant problem in the elderly.
  • Withdrawing the alpha-blocker component from BPH combination therapy can be considered after 1 year of combination therapy in patients whose symptoms have been well controlled.

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